(A) This rule describes how to calculate and
apply a restricted medicaid coverage period (RMCP) , which is the period of
time that long-term care (LTC) services will not be paid for by medicaid
because the institutionalized individual improperly transferred an asset.
(1) Total the value of all improperly
first month of requested payment of LTC services is less than a full calendar
month, an initial pro-rated period of restricted coverage (IPPRC) shall be
calculated as follows and is considered the first month of the RMCP:
(a) Determine the daily average private pay
rate (APPR) for nursing facility services in Ohio by dividing the monthly APPR
by the number of days in the month for which the first month of RMCP is being
calculated. Round the result to the second decimal place.
(b) Multiply the daily APPR by the number of
days from the first day of eligibility for requested LTC services through the
last day of the month in which the institutionalized individual is eligible for
medical assistance and would otherwise be receiving LTC services paid for by
the medicaid program.
Determine full months of RMCP as follows:
(a) Subtract the IPPRC from the total value
of all improperly transferred assets, if applicable; then
(b) Divide by the monthly APPR.
(c) The resulting whole number is the number
of full months of RMCP.
there is a remaining fractional amount, calculate a partial month of restricted
determine the partial month of restricted coverage (PMRC):
(a) Multiply the APPR by the number of full
months of restricted coverage; then
(b) Subtract that amount from the total value
of the improperly transferred assets; then
(c) Subtract the IPPRC determined in
paragraph (B)(2) of this rule; then
(d) The remainder is the amount of the PMRC.
If an institutionalized
individual is receiving any category of medical assistance at the time the
determination is made that assets were transferred for less than fair market
value, the RMCP will be effective on the
of the month following the expiration of the required notice period under rule
of the Administrative Code.
The first day of
the month following the expiration of the required notice period under rule
of the Administrative Code; or
The first day of
the month following the end of the quarter in which the COVID-19 public health
emergency declaration expires, in accordance with section 6008 of the Families
First Coronavirus Response Act (FFCRA) ( Pub. L. No. 116-127 ).
institutionalized individual is not receiving any category of medical
assistance at the time the determination is made that assets were transferred
for less than fair market value, the RMCP will be effective on the date on
which the institutionalized individual is eligible for medical assistance and
would otherwise be receiving LTC services paid for by the medicaid program but
for the imposition of the RMCP.
The RMCP cannot begin until the expiration of any already existing
(4) Once the RMCP is imposed,
it will not stop but will continue to run even if the individual subsequently
stops receiving LTC services.
The RMCP shall not be rounded down nor shall any PMRC be otherwise
Any PMRC shall be
applied as follows:
individual has a patient liability, the PMRC will be added to the
institutionalized individual's patient liability in the first month of
eligibility for LTC services. Refer to rules
to 5160:1-6-07.2 of the Administrative Code for the determination of the
individual does not have a patient liability, the individual is responsible for
paying his or her LTC provider the PMRC amount in the first month of
eligibility for LTC services.
a court has
entered an order against an institutionalized individual for the support of his
or her spouse, an RMCP shall not apply to amounts of assets transferred
pursuant to such order for the support of the spouse or a family
Any improper transfer
by a spouse that results in an RMCP for the institutionalized individual shall
be applied as follows:
spouse becomes an institutionalized individual, any remaining months of the
RMCP shall be apportioned between the spouses.
ceases to be institutionalized, any remaining months of the RMCP that has been
applicable to both spouses must be served by the spouse who continues to be
Treatment of new or newly discovered improper transfer of assets.
a new improper
transfer of assets occurs during an existing RMCP, a new RMCP shall be
calculated using only the new improper transfers and the APPR in effect at the
time of the calculation. The new RMCP shall be applied consecutively with the
(a) When there is a PMRC
calculated for both the existing RMCP and the new RMCP, combine the PMRCs.
PMRCs are greater than or equal to the monthly APPR, the result shall be an
additional month of RMCP and potentially a new PMRC amount. The
month of RMCP and PMRC shall be applied at
the end of the new RMCP.
improper transfers of assets that occurred
prior to the existing RMCP are newly discovered after the RMCP was calculated,
the existing RMCP shall be recalculated to include the newly discovered
improper transfers and using the APPR in effect when the existing RMCP was
of the assets that were improperly transferred are returned to the
institutionalized individual, no RMCP will be imposed.
(1) Return of the assets in question
to the institutionalized individual leaves the institutionalized individual
with assets which must be counted in redetermining eligibility for medical
(a) Counting those assets as
available may result in the institutionalized individual being ineligible for
medical assistance for some or all of the original RMCP, as well as for a
period of time after the assets are returned.
(b) The administrative agency must
redetermine eligibility for each month in the original RMCP and include the
returned assets as an available resource unless the asset would have otherwise
been considered an excluded asset.
(c) If an exclusion does not apply,
the asset is considered available to the institutionalized individual until the
total countable assets have been reduced to the appropriate resource
asset was sold by the person who received it, the full market value of the
asset must be returned to the institutionalized individual, either in cash or
another form that is commensurate with the original value. A return of any
amount less than the total value of all of the improperly transferred assets
will have no effect on the RMCP as calculated in this rule.
For the purpose of computing an overpayment under rule
of the Administrative Code, the returned asset or its equivalent must be
considered an available asset beginning in the month the asset was originally
RMCP resulting from an
improper transfer would
result in an undue hardship, the institutionalized individual can request an
undue hardship exemption in accordance with rule 5160:1-6-06.6 of the
Ohio Admin. Code
Five Year Review (FYR) Dates:
Effective Dates: 09/03/1977, 07/01/1982, 07/15/1984, 01/01/1985 (Emer.),
04/01/1985, 11/01/1986 (Emer.), 12/22/1986, 07/01/1987 (Emer.), 08/03/1987,
01/01/1990 (Emer.), 04/01/1990, 10/01/1990, 04/01/1995 (Emer.), 06/11/1995,
03/15/1996 (Emer.), 06/01/1996, 11/07/2002, 10/20/2006, 01/01/2016, 09/01/2017,
01/25/2019, 07/08/2020 (Emer.)